This is a summary of a professional paper that
was published originally in Hebrew at the Journal of Israeli Medical
Association and was translated to English and published at the United
Kingdom Paruresis Trust web site: (Click here for site)
"Bashful bladder" syndrome refers to the retention of
urine, without any organic finding. Under stress, sympathetic nervous system
activity can affect bladder output in one of two extreme ways: urinary
frequency, and urinary retention. Many who seek treatment for anxieties
complain of urinary frequency. This year, for the first time, there came under
my treatment three men who suffered from urinary retention when at a public
urinal or in proximity to others. The disorder is known in the literature as
"bashful bladder" or Paruresis.
In a sample of college students, Gruber and Shupe (1982) found
bashful bladder among 32% of the students and that their anxiety level was
higher than the norm. In personal conversation with a considerable number of
physicians, psychiatrists and psychologists, I found that despite the high
statistical incidence of the disorder, the number of those who seek
professional treatment is minuscule. A significant proportion of professionals
were not aware of this disorder at all.
The three males who came under my care in the course of one year
all complained of an almost identical disorder: an inability to urinate at a
public urinal whenever another male was in proximity. When urinating in an
enclosed stall in a public urinal, as soon as someone else entered the restroom
their flow would stop. When urinating in their bathroom at home or at any other
house, as soon as they heard noise from nearby – such as footsteps or the
turning of a faucet – their flow would stop. These patients would struggle to
urinate even in a place as "open" as a forest. Two of them developed
methods for avoiding urination when in close proximity to others, but the need
for isolation when urinating caused them distress. All three of the men noted
that the problem began at a very young age. They could not recall any traumatic
factor in the onset of the disorder. All three claimed that, apart from the
problem of bashful bladder, they had adapted to daily living and enjoyed a
sense of satisfaction – despite the fact that they considered themselves overly
sensitive and lacking in assertiveness.
The first male, age 18, came to me for treatment because he feared
the disorder would interfere with his adjustment to military reserve duty. The
second male, age 24, came under pressure from his girlfriend because the
disorder hindered them on outings with other couples. The third male, age 50,
came for treatment because his hospitalization had forced him to need a
catheter when he was unable to urinate using a bedside container. Faced with
the prospect of a second hospitalization, he wished to avoid another catheter.
In the framework of short-term psychological treatment, one is
aware of the great importance of explaining to the sufferer the root of their
disorder. The assumption is that "knowledge is power". When a patient
understands the cause of a disorder, he is less angry and less disappointed
with himself: For example, an accepted explanation for frequent urination when
in a pressured situation relates it to an evolutionary advantage. During an emergency
in the wild which stimulates the "fight or flight" response,
urination reduces body weight. In addition, in the event of a wound in the
region of the bladder, premature voiding tends to prevent its rupture. Since I
was unable to find in the professional literature any explanation of an
evolutionary advantage for urinary retention during an emergency, I was forced
to postulate such an advantage.
The first five sessions with each patient, were conducted once a
week. The sixth – which was designated for feedback – was spaced at almost a
month.
After receiving information about the disorder and a psychological
assessment of personality, each patient was given an evolutionary explanation
of the disorder. Below is a reconstructed text of the directive:
"When God or Nature created humans and living creatures,
there was planted in the brain a program which aimed to improve the chances of their
survival. We'll use as an example a deer standing in a forest and urinating. As
soon as a lion appears opposite it, the deer is faced with three possible
responses:
a. To politely ask the lion to wait until it is done urinating, and
after that flee;
b. To continue urinating even while fleeing;
c. To stop the flow of
urine and quickly flee. With disappearance of the danger, the flow of urine
will return.
I assume you'll agree with me that the third possibility is the
most logical. This is exactly what happens to you when you are urinating at a
public urinal. Since it is your character to be somewhat sensitive, in the
subconscious you feel like a creature exposed to attack. When a strange person
enters the restroom, or when you hear a noise nearby, the survival instinct
causes the bladder to instantly close and your body moves to act in a state of “Fight
or Flight”.
The problem is that the survival instinct was implanted millions
of years ago, when human life in the wild was established, and it hasn't been
revised since we came down from the trees. It may be compare to a computer
built at the beginning of the computer age, on whose hard drive was burnt a
specific program. Today the computer still processes well, but sometimes the
old program appears on the screen and interferes. It is very difficult to
delete an old program. I am a psychologist who specializes in “human computers.”
I will attempt to teach you, in a limited number of sessions, to delete the old
program whenever you want to urinate in the presence of strangers."
By means of metaphor, it was explained to each patient that their
body is like a car that works in two gears: a tranquil gear and a stress gear.
While in tranquil gear, each mechanism of the body works leisurely and muscle
tension is low. When in stress gear, each mechanism of the body is alert,
muscle tension increases and the bladder shuts down. They are going to learn
techniques how to transfer their body from a stress to a tranquil one.
The patients were inducted into a state of relaxation via
multi-varied techniques. While in this state, they were directed to imagine
that they are at a public urinal urinating next to a stranger. In addition,
each patient was instructed to evoke images concerning his individual problem.
The first patient was instructed to imagine that he was urinating in an open
field, alongside his buddy from the army. The second patient was directed to
imagine that he was urinating while on an outing with his friend, and the third
was instructed to imagine that he was urinating into a container while lying in
his bed at the hospital.
Toward the end of the third session, an individual program was
established which was scaled from the perspective of the problem. The patients
were instructed to practice it throughout the week. The goal of the program was
to prevail over the avoidant response in situations that stimulate urinary
retention. With the objective of diminishing expectations and preventing
disappointments, it was emphasized to each patient that the purpose was not to
urinate in public restrooms, but to practice "as if". For example:
To enter a public restroom and stand before a urinal with his fly
zipped. When a male enters to urinate, he should act as if he has just finished
and then exit the room.
1. to perform a similar exercise with the fly open
2. to perform a similar exercise with his penis visible
3. to enter an enclosed stall in a public restroom and practice
relaxation
4. to perform a similar exercise with his trousers unfastened.
5. to enter a bathroom at home and have housemates make noise in an
adjacent room
The sixth session, which was conducted about a month later, was
used for follow-up and support for continuing the exercise.
The two youngest patients were eager to practice both relaxation
and the imagery between sessions. At the fourth session, both reported their
success at urinating in various places under various conditions. They described
this as an intense experience such as they had not felt in years. At the sixth
session, they reported that they no longer felt a need to continue the
exercise.
The third patient reported more modest results. According to him,
he felt more comfortable urinating in public places, but avoided entering
restrooms if others were there. The sixth session was conducted after his
release from the second hospitalization. He reported feeling dependent on a
catheter only for the first day in the hospital, when he was confined to bed;
but when he was free to walk around the department, he was able to urinate in
the restroom after practicing relaxation. Although he was not completely free
of the disorder, he asked to discontinue treatment.
